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Applications Will Be Processed When Submitted Properly Completed. Be Sure To>Sign The Application. <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />ENGINEER'S AND/OR APPLICATION <br />APPLICANT'S AND/OR <br />ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />CONTRACTOR AND/OR <br />- - - - - <br />BROKER AND/OR <br />FOOD ESTABLISHMENTS, HOUSING <br />LICENSE AND/OR <br />PUBLIC POOLS. WATER SAMPLING <br />REGISTRATION <br />REAL ESTATE INSPECTIONS <br />NUMBER <br />POULTRY RANCHES AND KENNELS <br />- n ^ MISCELLANEOUS SERVICES <br />GENERAL <br />IF VEHICLE INVOLVED, GIVE <br />Make <br />Lic. No. <br />Regist. No. -- <br />Color_ — <br />rApplication Data Business/Name To A pear n er I <br />MType Permit/Service ReAuested' <br />Applicant Name �Mi iiX �- Address <br />i <br />._ Business TetApnione No. Emergency Telephone No. —V <br />(Property Location/Ad ess zz z— <br />Property Owner Address <br />L Operator's Name Address <br />1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br />❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br />❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br />❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br />❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br />❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br />❑ FOOD CROP HARVESTING/No. of Field Employees <br />ALL APPLICANTS: Total Employees Including Operators <br />Z. HOUSING <br />❑ HOTEL./MOTEVNO. of Units ❑ CERTIFICATE OF OCCUPANCY <br />❑ MOBILE HOME PARK/No. of Spaces <br />3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br />❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br />NO, OF PUBLIC SERVED (Connections) <br />a. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br />S. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br />❑ KENNEL/Runways /Animal Population No. No. of Confining Cages <br />bewage Ulapoaal mvu wa <br />Solid Waste Disposal Method <br />Water Supply Source Animal Waste Disposal Method <br />S. OXONSULTATION FEE ,BUSINESS LICENSE -- - — --- - -- <br />7. ❑ PLAN CHECKING FEE DANCE PERMIT - -- - — - - <br />B. REAL ESTATE <br />REQUEST: Water Well Inspection 13 Sample❑ Title Company <br />— --.— <br />Sewage System Inspection ❑ Address Tele. No. <br />_ — - — <br />Escrow No. <br />Seller Seller Address --- <br />Telephone No. Seller Agent Name - <br />Service Request For Date -- <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br />ordinances, state laws, and Tyles andwepulations 9th"eean Joaquin Local Health District. <br />APPLICANT'S SIGNATURE <br />Date / — �7b <br />ll - <br />FOR DEPARTMENT USE ONLY <br />71 fT .eru M .Iam,ary 1 S Received By January 31 ❑ July 1 S Received By July 31 <br />Fee IS UUa: W ANNUALu <br />u rm <br />I; - - <br />- - - - - <br />REMIT <br />BASE <br />EXPLANATION <br />BILLING <br />DATE <br />REMITTANCE S <br />DATE RE[MIITTED <br />AMOUNT DUE <br />CHECKED <br />AMOUNT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />�l <br />PENALTY <br />OTHER <br />OTHER <br />— <br />/// `, , 6? -7 -CL,/ —---- <br />Receive l by Del. ReO.,Pl No. Permit No Issuance Det- Mailed Delivered <br />- APPLICANT-RETX1 ALL-CORMSTO: ENVWONMENTAL HEALTH PERMIT/SERVICES 1801 E. HAZELTON AVE.. P.O. Bea 211110 STOCKTON, CA 86101 <br />